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Presentation to the Maryland Patient Safety Center 14th Annual Patient Safety Conference, Baltimore, Maryland
Rosemary Gibson, Author, Wall of Silence Senior Advisor, The Hastings Center
April 13, 2018
How Far We Have Come
How many of you believe
people are alive today because of
improvements in patient safety?
What do YOU think are the biggestaccomplishments in patient safety?
Take a Few Minutes to Talk
With Someone Seated Next To You
GAMECHANGERS
CONCLUSIONS
“An evidence-based intervention resulted in a
large and sustained reduction (up to 66%) in
rates of catheter-related bloodstream infection
that was maintained throughout the 18-month
study period.”
In other words…..infections are NOT
inevitable!
ANOTHER GAMECHANGER
What have YOU done that YOU are most proud of that has made care safer?
Take a Few Minutes to Talk
With Someone Seated Next To You
“This is the same hospital where my father died from a medical error. I was not impressed with things back then and I have many bad memories.
But ten years later we are here again. I am seeing many positive changes in safety culture and patient-centered practice. This reminds me of all the work we have done every day to make care safe. Collectively, we do make a huge difference in saving peoples’ lives.”
Daughter, wife, university researcher, state medical board public member, patient safety advocate
The Journey to Just Culture
Annie’s Story
and Just Culture
Patient: “I feel my glucose is really high.”
Tech and RN read the glucometer and interpreted it as reading the patient had critically high blood glucose
Here is what they saw….
The patient was given repeated doses of insulin.
The patient’s condition deteriorated and rapid response was called.
Patient was transferred to the ICU and given multiple doses of glucose
1. A hospital-level customization with a pop-up text message covered a critical reading.
2. The glucometer was poorly designed and allowed a pop-up text message to cover up essential information
What was the impact on Annie of a
lack of just culture?
It’s All About Culture
Speaking Up:
If You See Something Unsafe Say Something
(and Why We Don’t)
Audience Response System
On your phone, go to:
www.Menti.com
Question 1:
Do your colleagues speak up if they see something unsafe?
Answer choices
1. Always2. Sometimes 3. Rarely
Question 2:
Do you speak up if you see something unsafe?
Answer choices
1. Always
2. Sometimes
3. Rarely
“Drive out fear so everyone can work effectively.”
Deming
Do you think a department or hospital where staff feel safe speaking up has better
patient outcomes?
Data show a correlation between a culture where staff feel safe speaking up and patient outcomes
Thanks to Dr. Michael Leonard
No BSI 21%
No BSI = 5 months or more w/ zero
The strongest predictor of clinical excellence: caregivers feel
comfortable speaking up if they perceive a problem with patient care
No BSI 31% No BSI 44%
Attribution Bryan Sexton
28333641454549495152556262737580
98
0
20
40
60
80
100
Teamwork Climate Scores Across Facility
HCAHPS 9250
Medication Errors per Month 2.06.1
Days between C Diff Infections 12140
Days between Stage 3 Pressure Ulcers 5218
Illustrative Data:Extracted fromBlinded Client Data
Source: Dr. Michael Leonard
CULTURE IS RELATED TO…
28333641454549495152556262737580
98
0
20
40
60
80
100
Teamwork Climate Scores Across Facility
Employee Satisfaction 9155
Employee Injury per 1000 days 0.116
Employee Absenteeism per 1000 days 1015
RN Vacancy Rate 19
<60% Score = Danger Zone
Illustrative Data:Extracted fromBlinded Client Data
… AND UNFAVORABLE EMPLOYEE OUTCOMES
What Commitment Will You Make
To Continue On The Safety Journey –
Especially on Open and Honest Communication?
Take a Few Minutes to Talk
With Someone Seated Next To You
An Invitation!
Help The Next Generation Become
Committed to Patient Safety
The Telluride Patient Safety Summer Camp
4-day interprofessional summer immersion program in patient safety
Faculty are nationally-recognized patient safety leaders
Cost to medical and nursing students: $0
3 locations each summer: Colorado, Napa, California, Washington, D.C. suburbs
”This summer I had the amazing opportunity to attend a safety camp in Telluride, Colorado. Med students, nursing students, doctors and nurses from around the country were able to gather together in Telluride to expand our knowledge on patient safety. We spent the week discussing patient safety improvement, techniques, philosophy and approaches for reducing patient injury and adverse outcomes…
…It was an eye-opening week for me and I learned so much. The sense of empowerment I felt after the conference was incredible. Telluride truly has been the highlight of my nursing career thus far.”
Brennan Killeen, RN, BSN,
Clinical Nurse at MedStar Georgetown University Hospital
Telluride Scholar June 2015
To Learn More and Apply:
Google “Telluride Patient Safety”
In closing…
A moment to remember the gift
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